Providing ambulatory healthcare for people aged 80 and over: Views and perspectives of physicians and dentists from a qualitative survey

Background People aged 80 and over frequently face complex chronic conditions and health limitations, including oral health problems, which are primarily addressed by ambulatory (i.e., outpatient) healthcare. This demographic development is expected to affect the provision of care. However, few studies have investigated physicians’ and dentists’ views across the various medical disciplines in non-institutional settings. This study investigated how healthcare providers perceive caring for very old people, and how they feel healthcare should be designed for this patient group. Methods A qualitative online survey comprising nine open-ended items was conducted among physicians and dentists practicing in the ambulatory healthcare sector in North Rhine-Westphalia, Germany. Apart from child and adolescent healthcare, no medical specialties were excluded. The results were analysed using Kuckartz’ approach of structuring qualitative content analysis. A descriptive codebook was developed first. After coding all the material, recurring patterns between the topics were investigated and compared between two groups of participants, physicians and dentists. Results N = 77 cases were included in the analysis, from which n = 21 originated from the field of ambulatory general practice care and internal medicine, n = 19 from specialties (e.g., neurology, urology), and n = 37 from dentistry. Caring for patients aged 80 and over was perceived as challenging because of complex health conditions and treatments such as multimorbidity and polypharmacy, and patients’ cognitive and physical limitations. In characterizing good care in older age, both groups found individual care important, as well as empathetic interactions and good collaboration in networks of healthcare providers. Inadequate reimbursement and limited resources and time were the most important barriers to providing good care, while one of the most important facilitators was healthcare providers’ attitude and motivation. Conclusions Physicians’ and dentists’ conceptions of good healthcare are in line with the conceptualization of patient-centred care. However, the transfer in everyday care delivery is hampered by the current design of healthcare structures. Healthcare providers feel overstrained by the increasing demands placed on them. Adaptations for improvement should focus on building strong networks of cooperating health professions, especially including dental care, and local social support structures.


Round 1
• Period: 19/04/2021-25/04/2021 • Participants: n = 5 colleagues, professionals in the fields of health sciences, sociology, gerontology, speech therapy • Goal: general comprehensibility and arrangement of items, comments from a specialized perspective • General findings: o Clear wordingwhen is relation to health services explicitly and important, when not? o uniform gendering with gender star o Split some items into two items to achieve a clearer focus or to ensure that, for example, the request for an explanation is not overread "actually you only use one gender star…" ["eig. Macht man ja nun ein Gendersternchen…"] "perhaps a colour other than black? I would also write 'during your studies and further training as a specialist'. And does this age specification make sense here? As a study content, I rather imagine high age in general and less specifically the exact age limit. And is the question about specialist Adaptation of wording for a better understanding of the age phase, Normal selection scale instead of visual scale uniform gendering with gender star Divide into one item on study and one item on specialist training 1) In your opinion, how much time was spent during your academic education to discuss the care of over 80-year-old or very old patients? In the following, we would like to gain an insight into your work with patients aged 80 and over. For this purpose, we will now ask you a few open questions, which you can answer via a free text field. Please note three things: 1) You are free to answer the questions in bullet points or to describe them in more detail. However, whenever you can and would like to, we welcome brief explanations of your thoughts and reasons. This helps us to better understand your views. 2) "Care" does not only include medical aspects, but everything that is part of your daily or regular services.
"KO05 'what you consider part of the care provided on a daily basis' sounds a bit bumpy; maybe leave out the 'to'. I think the explanation is generally important, and could perhaps also be mentioned in the introduction." ["KO05 ‚was für Sie zur in der täglich erbrachten versorgung Adaptation of wording for a better understanding of the age phase, einheitliches Gendern mit Genderstern, In the following, we would like to gain an insight into your work with patients aged 80 and over. For this purpose, we will now ask you a few open questions, which you can answer via a free text field. Please keep three things in mind:

Original item
Answer options Comments Summary based on provided answers and comments

New item
3) Please avoid giving personal data such as names.
[ "KO05 I would write the second point more as a fact, i.e. without "we": e.g. "care" here does not only refer to medical aspects, but to everything that is part of the care provided for you on a daily basis." ["KO05 ich würde den zweiten Punkt eher als ein Fakt schreiben, also ohne "wir": z.B. "Versorgung" bezieht sich hier nicht nur auf medizinische Aspekte, sondern auf alles, was für Sie zur in der täglich erbrachten Versorgung dazugehört."] 1) You are free to answer the questions in bullet points or to describe them in more detail. However, whenever you can and would like to, we welcome brief explanations of your thoughts and reasons. This helps us to better understand your views.
2) "Care" is not only understood to mean medical aspects, but everything that is part of the services you provide on a daily or regular basis.
3) Please avoid giving personal data such as names.
[ 2) Why do you find these aspects enriching?

[2) Warum empfinden Sie diese Aspekte als bereichernd?]
What is going (rather) well or (rather) badly in your work with people aged 80 and over and why?
Text field: This is going (rather) well: "HC06: I find the question quite "general; is it specifically about the respective specialist care, is it The order is intended so that the following item (desired 1) What is going (rather) well in your work with people aged 80 and over and why?

Round 2
• Period: 15/09/2021-05/10/2021 • Participants: n = 6 (additionally two drop-outs), real-world sample, recruited via private/professional contacts, n = 3 of them from dentistry, 1x general/internal medicine, 1x otorhinolaryngology, 1x internal medicine • 20-29 year old: n = 2, 30-39 years old: n = 4, 40-49 years old: n = 2; male: n = 1, female: n = 7 • Goal: Comprehensibility, applicability and acceptance in the real-world sample • General findings: o Shorten or merge, also in the selection questions; there were some duplications, in addition, feedback came from two to three doctor networks that completion time is the critical factor o Separate reasons in a separate field not favourable, instead ask for description, encourage more writing o Shorten info text before open questions, do not encourage too many short answers o Particularly in the case of challenges with multiple enumeration, etc.: rather summarise and ask for description o Question about "what is (not) going well" does not work well and is sometimes perceived as a duplication; instead, integrate it into challenges o In the formulations, pay attention to the target group 80+ compared to younger groups o Instead of "care" use "practice, treatment" or similar. o Guide the participants through the questionnaire with "first part, second part, last part" so that they can keep going until the end In the following, we would like to gain an insight into your work with patients aged 80 and over. For this purpose, we will now ask you a few open questions, which you can answer via a free text field. Please keep three things in mind: 1) You are free to answer the questions in bullet points or to describe them in more detail. However, whenever you can and would like to, we welcome brief explanations of your thoughts and reasons. This helps us to better understand your views. 2) "Care" is not only understood to mean medical aspects, but everything that is part of the services you provide on a daily or regular basis. 3) Please avoid giving personal data such as names.

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Shorten and rather motivate to provide a a description; so far rather a suggestion to summarize In the following second part of the survey, we would like to gain an insight into your work with patients aged 80 and over.
Please note: We would be pleased if you could describe your personal perception in a few sentences. Your explanations will help us to better understand your daily work and your views.

Round 3 (final survey)
• Period: 06/10/2021-15/10/2021 • Participants: n = 7, real-world sample (additionally two drop-outs), of which n = 4 dentistry, 1x nuclear medicine, 1x human genetics, 1x dermatology • 20-29 years old: n = 1, 30-39 years old: n = 4, 40-49 years old: n = 2; male: n = 1, female: n = 6 • Goal: Comprehensibility, applicability and acceptance in the real-world sample • General findings: o The items work as intended o There were only a few comments, but after discussion in the research team, they were not relevant (for the aim of the study) o The survey draft is thus considered confirmed, no more changes will be made, the survey is ready for data collection In previous studies, we found that three basic motives shape the care wishes of people aged 80 and over: to feel safe, to feel like a meaningful human being, and to maintain autonomy and independence. What is the first thing you think of with regard to ensuring in care that patients aged 80 and over…